Privacy Notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective April 14, 2003, the New York Medicaid program must tell you howthe Department uses or shares we use, share, and protect your health information.information. The New York Medicaid program includes regular Medicaid, Medicaid Managed Care, Family Health Plus, and Child Health Plus A. The program is administered by the

New York State Department of Health and the Local Departments of Social Services.

and the Division of Health Care Access, New York City Department of Health operate the Medicaid, Family Health Plus and Child Health Plus A programs. The New York State Department of Health operates the Child Health Plus B program.

Your Health Information is Private.

We are required to keep your information private, share your information only when we need to, and follow the privacy practices in this notice. We must make special efforts to protect the names of people who get HIV/AIDS or drug and alcohol services.

What Health Information Does the New York Medicaid Program Have?

When you applied for Medicaid, Family Health Plus, or Child Health Plus A, you may have provided us with information about your health. When your doctors, clinics, hospitals, managed care plans and other health care providers send in claims for payment, we also get information about your health, treatments and medications.

If you enrolled in Child Health Plus B, the New York Medicaid program does not have your health information. You should contact your Child Health Plus B plan with questions about your health information.

How Do theDoes the New York Medicaid Program, Family Health Plus and Child Health Plus A&B Programs Does the Department of Health Use and Share Your Health Information?

We must share your health information when:

· You or your representative requests your health information.

· Government agencies request the information as allowed by law such as audits. The Department

· The law requires us the Department to share your information.

In your Medicaid application, you gave the New York Medicaid program the right to use and share your health information to pay for your health care and operate the program. For example, we use and share your information to:

· Pay your doctor, hospital, and/or other health care provider bills. The Department

· Make sure you receive quality health care and that all the rules and laws have been followed. We may review your health information to determine whether you received the correct medical procedure or health care equipment.

· The Department Contact you about important medical information or changes in your health benefits.

· Make sure you are enrolled in the right health program. The Department

· Collect payment from other insurance companies.

We may also use and share your health information under limited circumstances to:The Department

· Study health care. We may look at the health information of many consumers to find ways to provide better health care. The Department

· Prevent or respond to serious health or safety problems for you or your community as allowed by federal and state law.

We must have your written permission to use or share your health information for any purpose not mentioned in this notice.

What Are Your Rights?

You or your representative have the right to:

Ø Get a paper copy of this notice.

Ø See or get a copy of your health information. If your request is denied, you have the right to review the denial.

Ø Ask to change your health information. The Department We will look at all requests, but cannot change bills sent by your doctor, clinic, hospital or other health care provider.

Ø Ask to limit how the Department uses and shareswe use and share your information. WeThe Department will look at all requests, but does not have to agree to do what you ask.

Ø Askthe Department us to contact you regarding your health information in different ways (for example, you can ask theust to send your mail to a different address).

Ø Ask for special forms that you sign permitting the Departmentus to share your health information with whomever you choose. You can take back your permissionthe Department at any time, as long as the information has not already been shared.

Ø Get a list of those who received your health information. This list will not include health information requested by you or your representative, information used to operate the the New York Medicaid program or information given out for law enforcement purposes.

Child Health Plus A&B or Family Health PlusPlus or Child Health Plus A&B programs.

Ø See the New York State Department of Health Department’s w web site for a copy of this notice: www.health.state.ny.us.

1. For more privacy information, to make a request or to report a privacy problem/complaint*, please contact the Medicaid Help Line Office at: ( 518) 486-9057 or 1-800-541-2831. TTY users should call 1-800-662-1220. The Help Line will direct your calls to the correct state and local department of social services services officeand.

2. You may also report a complaint* to: The Office for Civil Rights, Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza, Suite 3312, New York, New York 10278; (Telephone) (212) 264-3313 or 1-800-368-1019; (Fax) (212) 264-3039; or (TDD) (212) 264-2355.

*You will not be penalized for filing a complaint.

The Department If we may change the information in this notice, . weWe will send you a new notice and post a new notice on the New York State Department of HealthDepartment’s web site.